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Revista argentina de cirugía

Print version ISSN 2250-639XOn-line version ISSN 2250-639X

Rev. argent. cir. vol.113 no.3 Cap. Fed. Sept. 2021

http://dx.doi.org/10.25132/raac.v113.n3.1542 

Articles

Solitary cecal ulcer as a rare cause of acute surgical abdomen

Alvar G. Rivera Romero1  * 

Sebastián A. Romero Núñez1 

Mariano Bulacio1 

Fernando D. Craievich1 

1 Servicio de Cirugía General, Hospital Misericordia del Nuevo Siglo HMNS. Córdoba. Argentina

In 1832, precisely in Limoges, France, Jean Cruveilhier, the most prominent French anatomist of the 19th century, described for the first time this solitary and non-specific ulcer of the colon which he usually observed in necropsies when he was 41 years old1. Barron also described this type of ulcers in his Atlas d’anatomie et pathologie in 19282.

Most patient present right lower quadrant pain mimicking an acute appendicitis, as in our case3-5, or symptoms suggestive of gastrointestinal bleeding, diverticulitis and colorectal cancer. The diagnosis is usually made after excluding other diseases and during surgery6,16.

In this article we analyze the case of a patient treated in the department of surgery of HMNS in April 2020.

Objective: to describe a case report and analyze the current status of an uncommon disease of the colon.

In this observational, descriptive and retrospective study we report the case of a patient with acute abdomen and symptoms suggestive of inflammation lasting 72 hours. The differential diagnoses are discussed. The patient’s personal data collected were age, personal and family history, time of pain progression and laterality, since the diagnosis is made by exclusion. The patient was followed-up in the outpatient clinic.

A 57-year-old female patient with a history of hypothyroidism, anxiety disorder and breast cancer sought medical care due to abdominal pain in the right iliac fossa that started 72 hours before and became progressively more severe. The pain was not associated with eating or bowel habits. She denied self-medication.

On physical examination blood pressure was 110/60 mm Hg, heart rate (HR) 100/min, respiratory rate (RR) 18/min, temperature 36.5°C, and oxygen saturation 99%. She had stabbing, non-radiating pain in the right iliac fossa 7/10 in intensity that increased on deep palpation. There were no masses or signs of rebound tenderness, and Blumberg sign and Rovsing sign were positive; she had generalized pallor but did not present nausea and vomiting.

The abdominal ultrasound showed a distended bowel loop with mural edema, loss of peristalsis and small amount of free fluid in the right iliac fossa (RIF) and Douglas’ pouch. The laboratory tests revealed increased CRP levels (15.3), low hemoglobin (Hb) (9.5 g/dL) levels and hematocrit (27.2%), with normal white blood cell count.

Contrast-enhanced computed tomography (CT) scan was not available in our hospital at the time of consultation to rule out an inflammatory process. We did not order colonoscopy or lower gastrointestinal series to avoid the complications associated with both procedures.

We decided to perform laparotomy via McBurney’s incision. As tumor was found in the cecum, we decided to proceed with segmental right colectomy with hand-sewn side-to-side ileocolostomy with absorbable polyglactin 3-0. There were no intraoperative complications.

The postoperative period was uneventful; the patient was discharged on postoperative day 5 and was followed-up in the outpatient clinic. There was no morbidity or mortality in our case.

The signs and symptoms of SCUs are nonspecific, and the disease has no pathognomonic signs. It is often misdiagnosed as acute appendicitis and appendiceal mass4,7, and gynecologic disorders such as endometriosis, ectopic pregnancy, and pelvic inflammatory disease (PID). It is difficult to differentiate from inflammatory bowel disease and colorectal carcinoma intraoperatively; for this reason, selective segmental resection is recommended in this case. The preoperative diagnosis is usually difficult, since the clinical presentation suggests appendicitis, tumor or perforation, which are more common diseases. Nevertheless, we understand that if this condition is considered during the bedside differential diagnosis, a preoperative diagnosis may be possible on some occasions. In the past, right hemicolectomy was recommended to guarantee radical oncologic treatment in case of cancer, but nowadays the tendency is to be less aggressive and to perform selective segmental colectomy, as in the case of this patient.

Specific etiologies of cecal ulcers include cytomegalovirus infection, particularly in immunocompromised individuals, use of non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives4, colon irritation cause by contents from the small intestine and primary or secondary vasculitis due to the use of NSAIDs or corticosteroids14,15.

Surgery is indicated when there are signs of peritonitis, perforation or uncontrolled bleeding and when cancer cannot be ruled out.

On gross examination, the pathology test demonstrates an ulceration resembling a peptic ulcer with a variable size between 0.5 and 5 cm in diameter, usually located on the antimesenteric border and with a well-demarcated transition zone between the normal tissue and the ulcer8. Edges are irregular and raised. Chronic ulcers show marked subserosal edema creating a false tumor-like appearance. Older lesions produce narrowing of the lumen. Most lesions are solitary, but multiple ulcers have been reported. Microscopically the ulcer shows fibrosis, necrotic granulation tissue with underlying inflammatory cells including lymphocytes, plasma cells, fibroblasts and occasionally eosinophils. Thrombosis in the microcirculation has also been mentioned.

The resected specimen shows a well-demarcated lesion with central ulceration and raised edges, 2.5 cm in diameter and 1 cm deep, is observed in the cecum, adjacent to the ileocecal valve (Fig. 1). Microscopically, there is marked submucosal and mural edema, with foci of intense inflammatory infiltrate of lymphocytes and plasma cells in clusters, some forming germinal centers, with abundant polymorphonuclear neutrophils (PMN) and eosinophils; congestive blood vessels, some of them dilated, and extravasation of red blood cells. There are areas with thrombosis in the microcirculation and hypertrophy of the muscle layer (Fig. 2).

Figure 1 A, B and C, well-demarcated lesion with central ulceration and raised edges, 2.5 cm in diameter and 1 cm in depth (arrow). 

Figure 2 Microphotography of surgical specimen (5x, hematoxylin and eosin). A, congested blood vessels (arrow). B, congested blood vessels, some are dilated, with areas of thrombosis (arrow). C, marked submucosal edema. 

These findings are suggestive of solitary cecal ulcer with nonspecific acute inflammatory changes, surgical margins free of lesions and vermiform appendix with minimal inflammatory changes.

Solitary cecal ulcer is an idiopathic disease with no sex predilection, although some studies have reported a 2:1 male predominance and that approximately 50% of all colonic ulcers are solitary14.

Solitary ulcers are most commonly located in the cecum (44%) and in the transverse colon (25%)9,10. The peak incidence is between 40 and 60 years19; but can occur at any age.

In conclusion, benign ulcer of the cecum is an uncommon condition that is difficult to diagnose clinically and in most cases requires surgical treatment17,18. Segmental resection is the recommended approach but hemicolectomy may be indicated in more complicated cases11-13.

Referencias bibliográficas /References

1. Shallman RW, Kuehner M, Williams GH, Sajjad S, Sautter R. Benign cecal ulcers: spectrum of disease and selective management. Dis Colon Rectum. 1985; 28:732-7. [ Links ]

2. Mark H, Ballinger W. Nonspecific ulcer of the colon. Report of a case and review of 51 cases from literature. Am J Gastroenterol. 1964; 41: 266-91. [ Links ]

3. Ateş KB, Şahin T, Gürkaynak G, Boyacıoğlu S. İdiyopatik çekum ül seri. Turkiye Klinikleri J Med Sci. 1991; 11:77-80. [ Links ]

4. Chi KD, Hanauer SB. Úlcera cecal solitaria benigna: reporte de un caso y revisión de la literatura. Dig Dis Sci. 2003; 48: 2207- 12. [ Links ]

5. Cha JM, Lee JI, Choe JW, Lee SH, Kim KY. Informe de un caso de úlcera cecal idiopática que imita el cáncer cecal. Dig Dis Sci. 2008; 53: 3259-62. [ Links ]

6. Barlow D. Simple ulcers of the cecum, colon, and rectum. Br J Surg. 1941; 28: 575-81. [ Links ]

7. Shah S, Sangwan P, Wongkar M, Patel N, Bajwa Q, Mehta P, y col. Úlcera cecal solitaria: un caso-informe y revisión de literatura. On col Gastroenterol Hepatol Rep. 2013; 2: 4-7. [ Links ]

8. Ong J, Lim KH, Lim JF, Eu KW. Síndrome de úlcera cecal solitaria: nuestra experiencia con esta afección benigna. Dis Colorrectal. 2011; 13:786-90. [ Links ]

9. Barlow D. Simple ulcers of the cecum, colon, and rectum. Br J Surg. 1941; 28: 575-81. [ Links ]

10. Smithwick W, Anderson RP, Ballinger WF. Nonspecific ulcer of the colon. Arch Surg. 1968; 97:133-8. [ Links ]

11. Ona FV, Allende HD, Vivenzio R, Zaky DA, Nadaraja N. Diagnosis and management of nonspecific colon ulcer. Arch Surg. 1982; 117: 888-94. [ Links ]

12. Mahoney T, Bubrick MP, Hitchcock CR. Nonspecific ulcers of the colon. Dis Colon Rectum. 1978; 21: 623-6. [ Links ]

13. Lipton S, Reisman E. Simple ulcer of the cecum. Ann Surg. 1951; 134:279-81. [ Links ]

14. Poggi Machuca L, Tagle Arróspide M, Cedrón Cheng H, Ibarra Chi rinos O, Camacho Zacarías, López Lasteros F. Úlcera cecal idiopática: reporte de un caso - Clínica Angloamericana. Lima, Perú. Rev Gastroenterol (Perú). 2013; 33 (4). Lima oct./dic. 2013 versión impresa ISSN 1022-5129. [ Links ]

15. Cohen GS, Shanahan CM. Benign Solitary Cecal Ulcer Syn drome Am J Gastroenterol. 2020; 115(3): 317. doi: 10.14309/ ajg.0000000000000347. [ Links ]

16. Bahar Büşra Özkan, Kadri Güleşçi, Nazan Aksoy, Yüksel Altınel . How Can We Diagnose Pre-malignant Solitary Cecal Ulcer? Turk J Colorectal Dis. 2018; 28:37-9. DOI: 10.4274/tjcd.96658. [ Links ]

17. Sala C, Mariani P, Siboni S, Piga S, Tagliabue F, Spinelli L, Novellino L. Surgical diagnosis of idiopathic cecal ulcer: presentation of two clinical cases. Int J Colorectal Dis. 2016; 31:703- 4. DOI 10.1007/s00384-015-2192-z. [ Links ]

18. Bhettani MK, et al. Isolated Nonspecific Colonic Ulcer: A Case Report From a Tertiary Care Hospital in Pakistan. Cureus 2019; 11(7):e5255. DOI 10.7759/cureus.5255. [ Links ]

19. Ong J, Lim KH, Lim JF, Eu KW. Síndrome de úlcera cecal solitaria: nuestra experiencia con esta enfermedad benigna. Enfermedad Colorrectal. 2011; 13:786-90. [ Links ]

Received: July 06, 2020; Accepted: October 30, 2020

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